Healthcare Provider Details

I. General information

NPI: 1801505441
Provider Name (Legal Business Name): MARY-ANN LYNN STOTHERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 16TH ST STE 202
SANTA MONICA CA
90404-1240
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 833-825-2974
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA52932
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberA52932
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: